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CS Form No.

212
Revised 2017

PERSONAL DATA SHEET


WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s aga
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do

I. PERSONAL INFORMATION
2. SURNAME BALEIN
NAME EXTENTION(JR.,SR)
FIRST NAME VIVIAN

MIDDLE NAME TEJONES


3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 11/20/1987 ✘ Filipino Dual Citizenship
by birth by
BRGY. CAROLINA CAN-AVID EASTERN
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate cou
SAMAR
please indicate the details.
5. SEX Male ✘ Female

17. RESIDENTIAL ADDRESS N/A CRISO


6 CIVIL STATUS Single ✘ Married
House/Block/Lot No. S
Widowed Separated
N/A CAR
Other/s: Subdivision/Village Bar
7. HEIGHT (m)
5'3 CAN-AVID EASTER
City/Municipality Pro
8. WEIGHT (kg) 66KG ZIP CODE 6806

18. PERMANENT ADDRESS N/A CRISO


9. BLOOD TYPE "A"
House/Block/Lot No. S
N/A CAR
10. GSIS ID NO. N/A
Subdivision/Village Bar
CAN-AVID EASTER
11. PAG-IBIG ID NO. 121188469490
City/Municipality Pro

12. PHILHEALTH NO. N/A ZIP CODE 6806

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 424-075-065 20. MOBILE NO. 09456788746

15. AGENCY EMPLOYEE NO. B15119 21. E-MAIL ADDRESS (if any) N/A

II. FAMILY BACKGROUND


22. SPOUSE'S SURNAME BALEIN 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME MICHAEL N/A

MIDDLE NAME ERAZO

OCCUPATION PHILIPPINE ARMY

EMPLOYER/BUSINESS NAME 87IB P.A

BUSINESS ADDRESS CATBALOGAN WESTERN SAMAR


TELEPHONE NO. N/A
24. FATHER'S SURNAME TEJONES
NAME EXTENSION (JR., SR)
FIRST NAME ESMERALDO N/A

MIDDLE NAME GERMANO

25. MOTHER'S MAIDEN NAME

SURNAME RAPATAN

FIRST NAME FELOMINA

MIDDLE NAME BOCIO (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND


NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY CAROLINA ELEMENTARY SCHOOL ELEMENTARY 1995 2001 GRADUATED


SECONDARY /
VOCATIONAL DOLORES NATIONAL HIGH SCHOOL HIGH SCHOOL 2000 2005 GRADUATED

N/A N/A N/A N/A N/A


TRADE
COURSE
COLLEGE LEYTE COLLEGES BACHELOR OF SCIENCE IN CRIMINOLOGY 2005 2009 GRADUATED

GRADUATE STUDIES N/A N/A N/A N/A N/A


(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOB

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM


DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

NAME EXTENTION(JR.,SR) N/A

Dual Citizenship

by naturalization
Pls. indicate country:

CRISOLOGO ST.
Street
CAROLINA
Barangay
EASTERN SAMAR
Province
6806

CRISOLOGO ST.
Street
CAROLINA
Barangay
EASTERN SAMAR
Province

N/A

09456788746

N/A

DATE OF BIRTH (mm/dd/yyyy)

N/A

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2001 N/A
2005 N/A

N/A N/A

2009 N/A

N/A N/A
parate sheet if necessary)
OCTOBER 7, 2019

CS FORM 212 (Revised 2017), Page 1 of 4


IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

BOARD OF CRIMINOLOGY 79.6 9/4/2013 TACLOBAN CITY

(Continue on separate sheet if necessary)


V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

1/1/2018 PRESENT FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 29,668.00 10-0

10/5/2017 12/31/2017 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 14,843.00 10-0

1/6/2015 9/5/2017 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 14,843.00 10-0

(Continue on separate sheet if necessary)


SIGNATURE DATE OCTOBER 7, 2019

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM 212 (R


LICENSE (if applicable)

NUMBER Date of
Validity

081130 11/20/2022

e on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet. GOV'T


SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT YES

PERMANENT YES

TEMPORARY YES

e on separate sheet if necessary)


OCTOBER 7, 2019

CS FORM 212 (Revised 2017), Page 2 of 4


VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / N
From To

N/A N/A N/A N/A

(Continue on separate sheet if necessary)


VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ S
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
BUREAU OF
SEMINARS ON BFP INFORMATION SYSTEM AND PETTY CASH 03/18/18 10/3/2018 24 TECHNICAL
REGIONAL O

FIRE BASIC RECRUIT COURSE 03/20/2017 4/8/2017 640 TECHNICAL NATIONAL F

BUREAU OF
FIRE OFFICER ORIENTATION PROGRAM 9/6/2015 9/8/2015 360 TECHNICAL
REGIONAL O

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

ARMED FO
COMPUTER LITERATE CERTIFICATE OF COMMENDATION/RECOGNITON/APPRECIATION
AND LO
ARMED FO
DRIVING MEDALYA NG PAPURI
BENE
(Continue on separate sheet if necessary)
SIGNATURE DATE O
BFP-QSF-HRMD-018 Rev. ØØ (05.04.18)
PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

arate sheet if necessary)


OGRAMS ATTENDED
ve (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

BUREAU OF FIRE PROTECTION


REGIONAL OFFICE 8

NATIONAL FIRE TRAINING INSTITUTE

BUREAU OF FIRE PROTECTION


REGIONAL OFFICE 8

arate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

ARMED FORCES AND POLICE SAVINGS


AND LOAN ASSOCIATION, INC.
ARMED FORCES AND POLICE MUTUAL
BENEFIT ASSOCIATION, INC.
arate sheet if necessary)
OCTOBER 7,2019
CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
YES ✘ NO
by any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA
7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:
a. Are you a member of any indigenous group? YES ✘ NO
If YES, please specify:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)


ID picture taken with
NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
(passport size)
BRGY.06, CAN-AVID EASTERN
SFO1 ANGEL R CAPADA JR SAMAR
9485943013 With full and handwri
name tag and signature
printed name

SFO2 RUFINO V ROBIENE JR SULAT EASTERN SAMAR 9276841736 Computer generate


or photocopied pictu
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
administrative/criminal case/s against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)


PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: BUREAU OF FIRE PROTECTION

ID/License/Passport No.: 8-B15119


Signature (Sign inside the box)
OCTOBER 7, 2019
Date/Place of Issuance: 03/14/2017/ BFP NHQ
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated ab

Person Administering Oath


BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM 212 (Revised
If YES, give details:
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________
✘ NO

✘ NO

✘ NO
If YES, give details (country):

✘ NO

✘ NO

✘ NO

ID picture taken within


the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten


name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4